1
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Brady BM, Zhao B, Dang BN, Winkelmayer WC, Chertow GM, Erickson KF. Patient-Reported Experiences with Dialysis Care and Provider Visit Frequency. Clin J Am Soc Nephrol 2021; 16:1052-1060. [PMID: 34597265 PMCID: PMC8425623 DOI: 10.2215/cjn.16621020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 04/19/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES New payment models resulting from the Advancing American Kidney Health initiative may create incentives for nephrologists to focus less on face-to-face in-center hemodialysis visits. This study aimed to understand whether more frequent nephrology practitioner dialysis visits improved patient experience and could help inform future policy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cross-sectional study of patients receiving dialysis from April 1, 2015 through January 31, 2016, we linked patient records from a national kidney failure registry to patient experience data from the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems survey. We used a multivariable mixed effects linear regression model to examine the association between nephrology practitioner visit frequency and patient-reported experiences with nephrologist care. RESULTS Among 5125 US dialysis facilities, 2981 (58%) had ≥30 In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems surveys completed between April 2015 and January 2016, and 243,324 patients receiving care within these facilities had Medicare Parts A/B coverage. Face-to-face practitioner visits per month were 71% with four or more visits, 17% with two to three visits, 4% with one visit, and 8% with no visits. Each 10% absolute greater proportion of patients seen by their nephrology practitioner(s) four or more times per month was associated with a modestly but statistically significant lower score of patient experience with nephrologist care by -0.3 points (95% confidence interval, -0.5 to -0.1) and no effect on experience with other domains of dialysis care. CONCLUSIONS In an analysis of patient experiences at the dialysis facility level, frequent nephrology practitioner visits to facilities where patients undergo outpatient hemodialysis were not associated with better patient experiences.
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Affiliation(s)
- Brian M. Brady
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Bo Zhao
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Bich N. Dang
- Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Glenn M. Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Kevin F. Erickson
- Selzman Institute for Kidney Health and Section of Nephrology, Baylor College of Medicine, Houston, Texas,Baker Institute for Public Policy, Rice University, Houston, Texas,Correspondence: Dr. Kevin F. Erickson, Baylor College of Medicine, 2002 Holcombe Boulevard, Mail Code 152, Houston, TX 77030.
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2
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Preka E, Shroff R, Stronach L, Calder F, Stefanidis CJ. Update on the creation and maintenance of arteriovenous fistulas for haemodialysis in children. Pediatr Nephrol 2021; 36:1739-1749. [PMID: 33063165 DOI: 10.1007/s00467-020-04746-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/02/2020] [Accepted: 08/26/2020] [Indexed: 11/27/2022]
Abstract
Arteriovenous fistulas (AVFs) are widely used for haemodialysis (HD) in adults with stage 5 chronic kidney disease (CKD 5) and are generally considered the best form of vascular access (VA). The 'Fistula First' initiative in 2003 helped to change the culture of VA in adults. However, this cultural change has not yet been adopted in children despite the fact that a functioning AVF is associated with lower complication rates and longer access survival than a central venous line (CVL). For children with CKD 5, especially when kidney failure starts early in life, there is a risk that all VA options will be exhausted. Therefore, it is essential to develop long-term strategies for optimal VA creation and maintenance. Whilst AVFs are the preferred VA in the paediatric population on chronic HD, they may not be suitable for every child. Recent guidelines and observational data in the paediatric CKD 5 population recommend switching from a 'Catheter First' to 'Catheter Last' approach. In this review, recent evidence is summarized in order to promote change in current practices.
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Affiliation(s)
- Evgenia Preka
- Southampton Children's Hospital and University of Southampton School of Medicine, Tremona Road, Southampton, SO16 6YD, UK.
| | - Rukshana Shroff
- UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Lynsey Stronach
- UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK
| | - Francis Calder
- UCL Great Ormond Street Hospital for Children Institute of Child Health, London, UK.,Evelina London Children's Hospital NHS Foundation Trust, London, UK
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3
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Stolić RV, Bukumiric Z, Mitrovic V, Sipic M, Krdzic B, Relic G, Nikolic G, Sovtic S, Suljkovic NE. Are There Differences in Arteriovenous Fistulae Created for Hemodialysis between Nephrologists and Vascular Surgeons? Med Princ Pract 2021; 30:178-184. [PMID: 33120382 PMCID: PMC8114068 DOI: 10.1159/000512632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/25/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Many studies have reported insufficient support from surgical services, resulting in nephrologists creating arteriovenous fistulas in many centers. The aim of this study was to compare risk factors of arteriovenous fistula dysfunction in patients whose fistulas were created by nephrologists versus vascular surgeons. METHODS This was a retrospective, analytical study of interventions by nephrologists and vascular surgeons during a period of 15 years. Out of a total of 1,048 fistulas, 764 (72.9%) were created by nephrologists patients, while vascular surgeons were responsible for 284 (27.1%) fistulae. Laboratory, demographic, and clinical parameters which might affect functioning of these arteriovenous fistulae were analyzed. RESULTS Patients whose arteriovenous fistula was formed by nephrologists differed significantly from those created by vascular surgeons in relation to the preventive character of the arteriovenous fistula (p = 0.011), lumen of the vein (p < 0.001) and systolic blood pressure (p = 0.047). Multivariate logistic regression of arteriovenous fistula dysfunction showed that risk factors were female gender (odds ratio [OR] = 1.56, 95% CI 1.16-2.07), whether the fistulae were created by vascular surgeons or nephrologists (OR = 1.38; 95% CI 1.01-1.89) and the site of the arteriovenous fistula (OR = 0.64; 95% CI 0.48-0.85). CONCLUSIONS Arteriovenous fistulae created by vascular surgeons, female gender, and the location are risk factors of dysfunction.
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Affiliation(s)
- Radojica V Stolić
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia,
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Vekoslav Mitrovic
- Faculty of Medicine Foca, University of East Sarajevo, Foca, Bosnia and Herzegovina
| | - Maja Sipic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Biljana Krdzic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Goran Relic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Gordana Nikolic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
| | - Sasa Sovtic
- Faculty of Medicine, University of Pristina/Kosovska Mitrovica, Kosovska Mitrovica, Serbia
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4
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Dahlerus C, Kim S, Chen S, Segal JH. Arteriovenous Fistula Use in the United States and Dialysis Facility–Level Comorbidity Burden. Am J Kidney Dis 2020; 75:879-886. [DOI: 10.1053/j.ajkd.2019.08.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 08/19/2019] [Indexed: 11/11/2022]
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Silver SA, Bota SE, McArthur E, Clemens KK, Harel Z, Naylor KL, Sood MM, Garg AX, Wald R. Association of Primary Care Involvement with Death or Hospitalizations for Patients Starting Dialysis. Clin J Am Soc Nephrol 2020; 15:521-529. [PMID: 32139363 PMCID: PMC7133142 DOI: 10.2215/cjn.10890919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 01/22/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES It is uncertain whether primary care physician continuity of care associates with a lower risk of death and hospitalization among patients transitioning to maintenance dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using provincial-linked administrative databases in Ontario, Canada, we conducted a population-based study of incident patients who initiated maintenance dialysis between 2005 and 2014 and survived for at least 90 days. We defined high primary care physician continuity as both a high usual provider of care index (where >75% of primary care physician visits occurred with the same primary care physician) in the 2 years before dialysis (an established measure of primary care physician continuity) and at least one visit with the same primary care physician in the 90 days after dialysis initiation. We used propensity scores to match a group of patients with high and low continuity so that indicators of baseline health were similar. The primary outcome was all-cause mortality, and secondary outcomes included all-cause and disease-specific hospitalizations during the 2 years after maintenance dialysis initiation. RESULTS We identified 19,099 eligible patients. There were 6612 patients with high primary care physician continuity, of whom 6391 (97%) were matched to 6391 patients with low primary care physician continuity. High primary care physician continuity was not associated with a lower risk of mortality (14.5 deaths per 100 person-years versus 15.2 deaths per 100 person-years; hazard ratio, 0.96; 95% confidence interval, 0.89 to 1.02). There was no difference in the rate of all-cause hospitalizations (hazard ratio, 0.96; 95% confidence interval, 0.92 to 1.01), and high primary care physician continuity was not associated with a lower risk of any disease-specific hospitalization, except for those related to diabetes (hazard ratio, 0.88; 95% confidence interval, 0.80 to 0.97). CONCLUSIONS High primary care physician continuity before and during the transition to maintenance dialysis was not associated with a lower risk of mortality or all-cause hospitalization.
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Affiliation(s)
- Samuel A Silver
- Division of Nephrology, Kingston Health Sciences Center, Queen's University, Kingston, Ontario, Canada; .,ICES, Toronto, Ontario, Canada
| | | | | | - Kristin K Clemens
- ICES, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism and Department of Epidemiology and Biostatistics and
| | - Ziv Harel
- ICES, Toronto, Ontario, Canada.,Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and
| | | | - Manish M Sood
- ICES, Toronto, Ontario, Canada.,Department of Medicine and Clinical Epidemiology Program of the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Amit X Garg
- ICES, Toronto, Ontario, Canada.,Division of Nephrology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Ron Wald
- ICES, Toronto, Ontario, Canada.,Division of Nephrology and Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; and
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6
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Anumudu SJ, Erickson KF. Physician reimbursement for outpatient dialysis care: Past, present, and future. Semin Dial 2020; 33:68-74. [DOI: 10.1111/sdi.12853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
| | - Kevin F. Erickson
- Section of Nephrology Baylor College of Medicine Houston Texas
- Baylor College of Medicine Center for Innovations in Quality, Effectiveness, and Safety Houston Texas
- Baker Institute for Public Policy Rice University Houston Texas
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7
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Shah S, Meganathan K, Christianson AL, Leonard AC, Thakar CV. Pre-dialysis acute care hospitalizations and clinical outcomes in dialysis patients. PLoS One 2019; 14:e0209578. [PMID: 30650094 PMCID: PMC6334901 DOI: 10.1371/journal.pone.0209578] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Accepted: 12/08/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD), a precursor of end stage renal disease (ESRD), face an increasing burden of hospitalizations. Although mortality on dialysis is highest during the first year, the impact of pre-dialysis acute hospitalizations on clinical outcomes in dialysis patients remains unknown. METHODS We evaluated 170,897 adult patients who initiated dialysis between 1/1/2010 and 12/31/2014 with linked Medicare claims from the United States Renal Data System. Using logistic regression models, we examined the association of 2-year pre-dialysis hospitalization on the primary outcome of 1-year all-cause mortality. Secondary outcomes included 90-day mortality, type of initial dialysis modality and type of vascular access at hemodialysis initiation. RESULTS Mean age was 72.7 ± 11.0 years. In the study sample, 76.0% of patients had at least one pre-dialysis hospitalization. Compared to patients with no pre-dialysis hospitalization, the adjusted 1-year mortality was higher with pre-dialysis cardiovascular related hospitalization (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.57-1.68), infection related hospitalization (OR, 1.51; CI, 1.45-1.57), both cardiovascular and infection hospitalization (OR, 1.91; CI, 1.83-1.99), and neither-cardiovascular nor-infection hospitalization (OR, 1.23; CI, 1.19-1.27). Additionally, the adjusted odds of hemodialysis vs. peritoneal dialysis as the initial dialysis modality were higher, whereas adjusted odds to initiate hemodialysis with an arteriovenous access vs. central venous catheter were lower in patients with any type of hospitalization. CONCLUSION Pre-dialysis hospitalization is an independent predictor of 1-year mortality in dialysis patients. Reducing the risk of pre-dialysis hospitalization may provide opportunities to improve quality of care in ESRD.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology, Kidney CARE Program, University of Cincinnati, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Karthikeyan Meganathan
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Annette L. Christianson
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Anthony C. Leonard
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Charuhas V. Thakar
- Division of Nephrology, Kidney CARE Program, University of Cincinnati, Cincinnati, Ohio, United States of America
- Division of Nephrology, VA Medical Center, Cincinnati, Ohio, United States of America
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8
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Boehm M, Bonthuis M, Noordzij M, Harambat J, Groothoff JW, Melgar ÁA, Buturovic J, Dusunsel R, Fila M, Jander A, Koster-Kamphuis L, Novljan G, Ortega PJ, Paglialonga F, Saravo MT, Stefanidis CJ, Aufricht C, Jager KJ, Schaefer F. Hemodialysis vascular access and subsequent transplantation: a report from the ESPN/ERA-EDTA Registry. Pediatr Nephrol 2019; 34:713-721. [PMID: 30588548 PMCID: PMC6394682 DOI: 10.1007/s00467-018-4129-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/06/2018] [Accepted: 10/22/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Current guidelines advocate use of arteriovenous fistula (AVF) over central venous catheter (CVC) for children starting hemodialysis (HD). European data on current practice, determinants of access choice and switches, patient survival, and access to transplantation are limited. METHODS We included incident patients from 18 European countries who started HD from 2000 to 2013 for whom vascular access type was reported to the ESPN/ERA-EDTA Registry. Data were evaluated using descriptive statistics, logistic and Cox regression models, and cumulative incidence competing risk analysis. RESULTS Three hundred ninety-three (55.1%) of 713 children started HD with a CVC and were more often females, younger, had more often an unknown diagnosis, glomerulonephritis, or vasculitis, and lower hemoglobin and height-SDS at HD initiation. AVF patients were 91% less likely to switch to a second access, and two-year patient survival was 99.6% (CVC, 97.2%). Children who started with an AVF were less likely to receive a living donor transplant (adjusted HR, 0.30; 95% CI, 0.16-0.54) and more likely to receive a deceased donor transplant (adjusted HR, 1.50; 95% CI, 1.17-1.93), even after excluding patients who died or were transplanted in the first 6 months. CONCLUSIONS CVC remains the most frequent type of vascular access in European children commencing HD. Our results suggest that the choice for CVC is influenced by the time of referral, rapid onset of end-stage renal disease, young age, and an expected short time to transplantation. The role of vascular access type on the pattern between living and deceased donation in subsequent transplantation requires further study.
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Affiliation(s)
- Michael Boehm
- Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Marjolein Bonthuis
- Department of Medical Informatics, Amsterdam Public Health research institute, ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Marlies Noordzij
- Department of Medical Informatics, Amsterdam Public Health research institute, ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jaap W. Groothoff
- Department of Paediatric Nephrology, Emma Children’s Academic Medical Center, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | | | - Jadranka Buturovic
- Department of Nephrology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Ruhan Dusunsel
- Department of Pediatric Nephrology, Erciyes University Medical Faculty, Kayseri, Turkey
| | - Marc Fila
- Department of Pediatric Nephrology, Montpellier University Hospital, Montpellier, France
| | - Anna Jander
- Department of Pediatrics, Immunology and Nephrology, Polish Mothers Memorial Hospital Research Institute, Łódź, Poland
| | - Linda Koster-Kamphuis
- Department of Pediatric Nephrology, Amalia Children’s Hospital Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gregor Novljan
- Pediatric Nephrology Department, Children’s Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Pedro J. Ortega
- Department of Pediatric Nephrology, Hospital Universitari La Fe, Valencia, Spain
| | - Fabio Paglialonga
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca’Granda Ospedal Maggiore Policlinico, Milan, Italy
| | - Maria T. Saravo
- Nephrology and Dialysis Unit, Santobono Children’s Hospital, Naples, Italy
| | | | - Christoph Aufricht
- Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Kitty J. Jager
- Department of Medical Informatics, Amsterdam Public Health research institute, ESPN/ERA-EDTA Registry and ERA-EDTA Registry, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children’s Hospital, Heidelberg, Germany
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9
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Erickson KF, Winkelmayer WC. Evaluating the Evidence behind Policy Mandates in US Dialysis Care. J Am Soc Nephrol 2018; 29:2777-2779. [PMID: 30389727 DOI: 10.1681/asn.2018090905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Kevin F Erickson
- Department of Medicine, Selzman Institute for Kidney Health, Section of Nephrology, and .,Department of Medicine, Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, Houston, Texas; and.,Baker Institute for Public Policy, Rice University, Houston, Texas
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10
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Kshirsagar AV, Tabriz AA, Bang H, Lee SYD. Patient Satisfaction Is Associated With Dialysis Facility Quality and Star Ratings. Am J Med Qual 2018; 34:243-250. [PMID: 30223675 DOI: 10.1177/1062860618796310] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Dialysis Facility Compare Star Rating and the Quality Incentive Program (QIP) generate separate performance scores from clinical measures, and the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH-CAHPS) survey evaluates patient satisfaction across 6 separate domains related to nephrologists, dialysis facility, and information transmission. This study examined the relationship of the 3 measures for US clinics, modeling the 6 ICH-CAHPS domains as independent variables and QIP and star ratings as dependent variables. Among 3176 dialysis clinics, domains assessing dialysis facility and information transmission had a consistently stronger relationship with QIP and star ratings than the domains assessing nephrologists: QIP, β (95% CI) = 1.62 (1.26-1.97) for dialysis facility staff rating, 0.70 (0.35-1.05) for nephrologists; star rating, odds ratio (95% CI) = 1.38 (1.29-1.49) for dialysis facility staff rating, 1.17 (1.09-1.25) for nephrologists. Patient satisfaction is associated with dialysis care quality, with surprising differences between nephrologists and dialysis facilities.
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11
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Woodside KJ, Bell S, Mukhopadhyay P, Repeck KJ, Robinson IT, Eckard AR, Dasmunshi S, Plattner BW, Pearson J, Schaubel DE, Pisoni RL, Saran R. Arteriovenous Fistula Maturation in Prevalent Hemodialysis Patients in the United States: A National Study. Am J Kidney Dis 2018; 71:793-801. [PMID: 29429750 DOI: 10.1053/j.ajkd.2017.11.020] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/22/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Arteriovenous fistulas (AVFs) are the preferred form of hemodialysis vascular access, but maturation failures occur frequently, often resulting in prolonged catheter use. We sought to characterize AVF maturation in a national sample of prevalent hemodialysis patients in the United States. STUDY DESIGN Nonconcurrent observational cohort study. SETTING & PARTICIPANTS Prevalent hemodialysis patients having had at least 1 new AVF placed during 2013, as identified using Medicare claims data in the US Renal Data System. PREDICTORS Demographics, geographic location, dialysis vintage, comorbid conditions. OUTCOMES Successful maturation following placement defined by subsequent use identified using monthly CROWNWeb data. MEASUREMENTS AVF maturation rates were compared across strata of predictors. Patients were followed up until the earliest evidence of death, AVF maturation, or the end of 2014. RESULTS In the study period, 45,087 new AVFs were placed in 39,820 prevalent hemodialysis patients. No evidence of use was identified for 36.2% of AVFs. Only 54.7% of AVFs were used within 4 months of placement, with maturation rates varying considerably across end-stage renal disease (ESRD) networks. Older age was associated with lower AVF maturation rates. Female sex, black race, some comorbid conditions (cardiovascular disease, peripheral artery disease, diabetes, needing assistance, or institutionalized status), dialysis vintage longer than 1 year, and catheter or arteriovenous graft use at ESRD incidence were also associated with lower rates of successful AVF maturation. In contrast, hypertension and prior AVF placement at ESRD incidence were associated with higher rates of successful AVF maturation. LIMITATIONS This study relies on administrative data, with monthly recording of access use. CONCLUSIONS We identified numerous associations between AVF maturation and patient-level factors in a recent national sample of US hemodialysis patients. After accounting for these patient factors, we observed substantial differences in AVF maturation across some ESRD networks, indicating a need for additional study of the provider, practice, and regional factors that explain AVF maturation.
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Affiliation(s)
- Kenneth J Woodside
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Sarah Bell
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Purna Mukhopadhyay
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Kaitlyn J Repeck
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Ian T Robinson
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Ashley R Eckard
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Sudipta Dasmunshi
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI
| | - Brett W Plattner
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Jeffrey Pearson
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Douglas E Schaubel
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Ronald L Pisoni
- Arbor Research Collaborative for Health, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, MI; Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI.
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12
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Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Hemodialysis Hospitalizations and Readmissions: The Effects of Payment Reform. Am J Kidney Dis 2017; 69:237-246. [PMID: 27856087 PMCID: PMC5263112 DOI: 10.1053/j.ajkd.2016.08.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 08/11/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND In 2004, the Centers for Medicare & Medicaid Services changed reimbursement for physicians and advanced practitioners caring for patients receiving hemodialysis from a capitated to a tiered fee-for-service system, encouraging increased face-to-face visits. This early version of a pay-for-performance initiative targeted a care process: more frequent provider visits in hemodialysis. Although more frequent provider visits in hemodialysis are associated with fewer hospitalizations and rehospitalizations, it is unknown whether encouraging more frequent visits through reimbursement policy also yielded these benefits. STUDY DESIGN We used a retrospective cohort interrupted time-series study design to examine whether the 2004 nephrologist reimbursement reform led to reduced hospitalizations and rehospitalizations. We also used published data to estimate a range of annual economic costs associated with more frequent visits. SETTING & PARTICIPANTS Medicare beneficiaries in the United States receiving hemodialysis in the 2 years prior to and following reimbursement reform. PREDICTOR The 2 years following nephrologist reimbursement reform. OUTCOMES Odds of hospitalization and 30-day hospital readmission for all causes and fluid overload; US dollars. RESULTS We found no significant change in all-cause hospitalization or rehospitalization and slight reductions in fluid overload hospitalization and rehospitalization following reimbursement reform; the estimated economic cost associated with additional visits ranged from $13 to $87 million per year, depending on who (physicians or advanced practitioners) spent additional time visiting patients and how much additional effort was involved. LIMITATIONS Due to limited information about how much additional time providers spent seeing patients after reimbursement reform, we could only examine a range of potential economic costs associated with the reform. CONCLUSIONS A Medicare reimbursement policy designed to encourage more frequent visits during outpatient hemodialysis may have been costly. The policy was associated with fewer hospitalizations and rehospitalizations for fluid overload, but had no effect on all-cause hospitalizations or rehospitalizations.
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Affiliation(s)
- Kevin F Erickson
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX; Center for Innovations in Quality, Effectiveness and Safety, Baylor College of Medicine, Houston, TX.
| | - Wolfgang C Winkelmayer
- Section of Nephrology, Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, TX
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Jay Bhattacharya
- Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA
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Erickson KF, Winkelmayer WC, Chertow GM, Bhattacharya J. Effects of physician payment reform on provision of home dialysis. THE AMERICAN JOURNAL OF MANAGED CARE 2016; 22:e215-23. [PMID: 27355909 PMCID: PMC5055389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Patients with end-stage renal disease can receive dialysis at home or in-center. In 2004, CMS reformed physician payment for in-center hemodialysis care from a capitated to a tiered fee-for-service model, augmenting physician payment for frequent in-center visits. We evaluated whether payment reform influenced dialysis modality assignment. STUDY DESIGN Cohort study of patients starting dialysis in the United States in the 3 years before and the 3 years after payment reform. METHODS We conducted difference-in-difference analyses comparing patients with traditional Medicare coverage (who were affected by the policy) to others with Medicare Advantage (who were unaffected by the policy). We also examined whether the policy had a more pronounced influence on dialysis modality assignment in areas with lower costs of traveling to dialysis facilities. RESULTS Patients with traditional Medicare coverage experienced a 0.7% (95% CI, 0.2%-1.1%; P = .003) reduction in the absolute probability of home dialysis use following payment reform compared with patients with Medicare Advantage. Patients living in areas with larger dialysis facilities (where payment reform made in-center hemodialysis comparatively more lucrative for physicians) experienced a 0.9% (95% CI, 0.5%-1.4%; P < .001) reduction in home dialysis use following payment reform compared with patients living in areas with smaller facilities (where payment reform made in-center hemodialysis comparatively less lucrative for physicians). CONCLUSIONS The transition from a capitated to a tiered fee-for-service payment model for in-center hemodialysis care resulted in fewer patients receiving home dialysis. This area of policy failure highlights the importance of considering unintended consequences of future physician payment reform efforts.
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Affiliation(s)
- Kevin F Erickson
- Center for Innovations in Quality, Effectiveness, and Safety, Baylor College of Medicine, 2002 Holcombe Blvd, Mail Code 152, Houston, TX 77030. E-mail:
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Sherman RA. Briefly Noted. Semin Dial 2016. [DOI: 10.1111/sdi.12447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Heung M, Faubel S, Watnick S, Cruz DN, Koyner JL, Mour G, Liu KD, Cerda J, Okusa MD, Lukaszewski M, Vijayan A. Outpatient Dialysis for Patients with AKI: A Policy Approach to Improving Care. Clin J Am Soc Nephrol 2015. [PMID: 26220818 DOI: 10.2215/cjn.02290215] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The rate of AKI requiring dialysis has increased significantly over the past decade in the United States. At the same time, survival from AKI seems to be improving, and thus, more patients with AKI are surviving to discharge while still requiring dialysis. Currently, the options for providing outpatient dialysis in patients with AKI are limited, particularly after a 2012 revised interpretation of the Centers for Medicare and Medicaid Services guidelines, which prohibited Medicare reimbursement for acute dialysis at ESRD facilities. This article provides a historical perspective on outpatient dialysis management of patients with AKI, reviews the current clinical landscape of care for these patients, and highlights key areas of knowledge deficit. Lastly, policy changes that have the opportunity to significantly improve the care of this at-risk population are suggested.
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Affiliation(s)
- Michael Heung
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Sarah Faubel
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.
| | - Suzanne Watnick
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Dinna N Cruz
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jay L Koyner
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Girish Mour
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Kathleen D Liu
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Jorge Cerda
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Mark D Okusa
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Mark Lukaszewski
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
| | - Anitha Vijayan
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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16
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Mutevelic A, Spanja I, Sultic-Lavic I, Koric A. The impact of Vascular Access on the Adequacy of Dialysis and the Outcome of the Dialysis Treatment: One Center Experience. Mater Sociomed 2015; 27:114-7. [PMID: 26005389 PMCID: PMC4404955 DOI: 10.5455/msm.2015.27.4-114-117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/03/2015] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Chronic kidney disease (CKD) is a gradually reduction in glomerular filtration rate (GFR) caused by destruction of a large number of nephrons. Kidney failure is the final stage of CKD with GFR <15ml/min/1.73m(2) or requiring dialysis. Patients must provide vascular access, which is also the "life line" and "Achilles heel" of hemodialysis treatment. AIM The purpose of this research is to show the demographic structure of the hemodialysis center in Konjic, and also demonstrate the impact of vascular access to the adequacy and the outcome of dialysis treatment. METHODS This cross-sectional study included 36 patients on hemodialysis in Center in Konjic from September 2010 to December 2014. The method of collecting data is performed through medical records and the quality of dialysis is taken to be Kt/V> 1.2. Statistical analysis was performed using SPSS software and Student T-test. RESULTS The mortality of patients treated by dialysis is 37.8%. The ratio of male and female patients is 55.6% vs. 44.5%, with an average age of 52.91±14.36 years and an average duration of hemodialysis of five years. The highest percentage of patients dialyzed through arterio-venous fistula (AVF) on the forearm (72.2%). In that patients the most common complication is thrombosis with 30.5%, which require recanalization in 11% and replacement in 19.5% of patients. Of the other dialysis patients, 16.7% of patients are dialyzed via a temporary and 11.1% via a permanent catheter (the most common complication in that patients is infection in 83.3% cases) in v.subclavia. Although the AVF is more frequently, experience shows frequent implantation of a permanent catheter in elderly patients due to the less quality of their blood vessels. Although the Kt/V by patients who are dialyzed through temporary catheter is less than 1.2 and by the other two access is greater than 1.2, our results confirm that vascular access does not have an influence on quality of dialysis. Average Kt/V shows that the adequate dialysis dose is delivered in this Center, which means that despite the impact of vascular access in HD quality, other factors also can affect on dialysis treatment, which was noticed by patients and staff. CONCLUSION Despite the largest mortality rate in patients with a permanent catheter and least in patients with AVF, the type of vascular access does not affect the outcome of dialysis treatment.
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Affiliation(s)
| | - Indira Spanja
- General Hospital Konjic, Konjic, Bosnia and Herzegovina
| | | | - Amila Koric
- General Hospital Konjic, Konjic, Bosnia and Herzegovina
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